"Alternative Medicine"
and the Psychology of Belief

James Alcock, Ph.D.

In 1988, I was part of a six-person delegation from the Committee
for the Scientific Investigation of Claims of the Paranormal (CSICOP)
that visited the People's Republic of China. We had been invited
to investigate (a) Qi Gong, a vitalistic belief system that, among
other things, is employed to diagnose and heal disease, and (b)
the abilities of a group of children who, it was claimed, could
read with their armpits. During our stay in Beijing, I developed
a very sore throat, due, I thought, to the visibly polluted air.
This made it difficult to engage in conversations and deliver
the speeches that were expected of us. Eventually, I was taken
to the outpatient clinic at Beijing Hospital, where, after a very
brief examination, was given two medications. The first, labeled
in both Chinese and English, was erythromycin, an antibiotic.
That seemed reasonable enough for what I thought to be a bronchial
infection. The second medication was labeled "Chuanbeiye,"
with the chief ingredients listed as "snake bile, tendril-leafed
fritillary bulb, and almond, etc." Our interpreter assured
me that she always relied on the snake bile preparation whenever
she had any throat problems, but despite her earnest testimonial,
I declined to use it. I relied instead upon the erythromycin,
and within a few days, my throat recovered. Offered folk medicine
and snake oil, I had chosen scientific Western medicine and was
healed by it.

Or so I thought. After our return from China, Paul Kurtz recounted
this incident in an article in CSICOP's journal, the Skeptical
Inquirer. A few months later, a physician responded in letter
to the editor:

All too often bronchial infections are due to viruses and
therefore not treatable with antibiotics. Unfortunately, there
is such a demand from the lay public to treat everything with
antibiotics that it is not unusual for the encumbered physician
to prescribe them for infections they know cannot be helped by
antibiotics. . . . If this was a viral infection, then the antibiotic
and the snake bile were of equal efficacy [1].

But I got better, didn't I? Doesn't that tell me that the antibiotic
worked?

When we talk about the appeal of this treatment or that treatment,
this is what is at the heart of it all—we use medicines because
they seem to work. If we get better, we naturally credit the treatment
(whether it had any effect or not). And when we do not improve,
we naturally assume that the treatment did not work, and we may
then seek out other therapies that might.

So-called alternative or complementary therapies are popular
only to the extent that they can satisfy some people's needs better
than conventional medical therapies do. If every visit to the
family physician cured our complaints and satisfied our needs
(the two are not necessarily the same), then the vast majority
of people would never consider alternate therapies. And if, once
people tried alternative therapies, they did not seem to be effective,
most people would stop using them and they would eventually die
out.

It is a mistake to assume that people who use unproven or even
disproven therapies are generally less rational, less sensible,
or even less educated than those who do not. Most surveys show
that users of alternative medicine tend to have more years of
formal education than nonusers—a by-product of the fact that
these users must generally pay out of their own pockets and thus
must have more disposable income [2]. No one that I have ever
met would knowingly submit to treatment that he or she believed
to be totally useless or harmful. We pursue a therapy because
we believe—or at least hope—that it may work. (This may
not apply, of course, to the radical fringe, people for whom use
of alternative medicine is an integral part of an overarching
sociopolitical, antiscience, or New Age worldview.)

The interesting question is how we come to believe that a therapy
may be worthwhile. And since none of us is likely (even if we
possess the necessary knowledge, skills, and wherewithal) to carry
out clinical trials before choosing a treatment for the first
time, we must ultimately base our initial decision on our faith
in others' opinions and even, perhaps, others' research. However,
once we decide to try a therapy, our own experience becomes very
important, and a variety of psychological factors come into play
that may help persuade us that the therapy is effective, even
if it is not.

Most people turn to and believe in alternative therapies for
the same reasons they turn to and believe in evidence-based medicine.
Most users of alternative medicine are ignorant of, and uninterested
in, the theoretical basis of homeopathy or chiropractic or naturopathy,
just as most users of evidence-based medicine are ignorant of
and uninterested in its theoretical underpinnings. Physicians
have taught us not to enquire too much about what is in this tablet
or how that injection works. We wouldn't be able to understand
it anyway, and after all, we have come to the physician because
we trust that he or she understands so that we don't have to.
Most people who keep using alternative therapies do so because
they believe it helps, just as is the case with those who continue
to go back for treatment with evidence-based therapies.

In the end, it boils down to what our individual belief systems
incline us to accept as evidence. This article discusses how we
learn about causality, how our beliefs and our trust develop,
and how this shapes our concepts of illness and healing. It is
through these mechanisms that people come to have confidence in
any therapy, evidence-based or not, and effective or not.

How We Learn About Causality

When I stated earlier that the antibiotic made me better, what
did that statement actually mean? In reality, all that happened
was that two events occurred in succession: One, I took the medicine,
and two, not too long afterwards, I felt better. Yet, my conclusion
was a causal one: The medicine made me better. That is consistent
with my limited knowledge of medicine and my expectations. Since
I knew nothing directly about the causal link, or even for sure
if there was one, my judgement was really magical thinking. Magical
thinking describes what happens when we experience two successive
events and conclude that the first event caused the second, without
any concern for the putative causal link. All humans are to some
degree magical thinkers. Until recently, most psychologists used
to think that textbook logic and reasoning practices were the
"default mode," and that when people engaged in magical
or superstitious thinking it was some kind of pathology, a deviation
from the inbred norm. Research has taught us, however, that magical
thinking (i.e., "quick-and-dirty" reasoning tactics
that get it more or less right a sufficient portion of the time
to be useful) is our first line of attack when reckoning with
the world—logical, analytical reasoning is a fragile add-on
that must be painstakingly learned [3-5].

We actually have two quite distinct information-processing
systems in our brains and nervous systems that lead us to conclusions
about causality. On the one hand, we learn quickly from direct
experience. Put your finger in a live lamp socket, and your experience
quickly teaches you not to do that again. This is experiential
learning. No knowledge of electricity, no understanding of physics,
is necessary. A dumb animal would learn as quickly not to touch
the socket again. On the other hand, we also process information
in an intellectual manner, through reasoning, logic, and analysis.
Through intellectual learning, we come to know that a flow of
electrons races down our finger when we touch a live contact point
in the socket, and we can learn to avoid touching sockets even
if we have never had any direct experience with them.

Experiential Learning

Experiential learning occurs at a primitive level—it is
automatic, rapid, and often tied up with emotional reactions.
It requires no formal teaching, no practice, no theoretical understanding,
no contemplation, no logic. It is based on patterns that we detect
in the world around us.

We enter this world superbly equipped to learn quickly about
our environment. Our nervous systems are bombarded with an unending
shower of sensory stimulation from both within and without our
bodies. We are able at birth to begin to find patterns in this
stimulation, to make sense out of it. To do so we rely on two
factors—temporal contiguity and stimulus generalization. By
temporal contiguity, I mean that events that occur closely together
in time have a special impact on our nervous systems; they set
up an "association" in our brains. Touch a hot stove,
feel pain, and the nervous system "learns" to avoid
the hot stove. And then, by the process of stimulus generalization,
one learns not only to avoid that stove, the one that caused the
pain, but other stoves and any object that looks similar to that
stove. In other words, without the need for any reasoning or logic
or words or understanding, we quickly internalize some "knowledge"
about the world—don't touch stoves; they cause pain. The importance
of such learning for survival is obvious. Yet, again, note the
imputation of causality, when all we really experience is temporal
contiguity. This applies just as readily to positive outcomes:
Take a pill and the headache goes away. We attribute the pain
relief to the pill.

Asymmetric effect of pairing and nonpairing. It is important
to understand, as I have discussed in detail elsewhere [6,7],
that we do not easily unlearn associations between important events.
If the infant, by accident, touches the same stove a day later,
but this time it is cold and so no pain occurs, his or her nervous
system does not simply reset to itself to zero so far as stoves
are concerned. Obviously, this would not be very adaptive in terms
of our survival: The rabbit that encounters a snarling, biting
fox and lives to remember it would not be well served by a nervous
system that unlearns the fear of foxes, just because on one occasion,
the rabbit encounters a fox that makes no effort to turn it into
dinner. The association set up by the co-occurrence of two significant
events is not easily undone. If your migraine went away last week
when you took a pill, but did not abate when you took another
pill today, would you decide that the pill does not work after
all? Not likely.

Intermittent reinforcement. Indeed, what happens if,
ten times in a row, the child accidentally brushes against the
stove, but the stove is cool? With an accumulation of such experiences,
the association between stove and pain will gradually weaken,
but—and this is a very important "but"—if every
now and then touching the stove produces pain, this results in
an even more enduring association between stove and pain, for
one automatically learns that the fact that the stove was harmless
enough—even a number of times in a row—does not mean that
it will not burn the next time. Occasional, intermittent reinforcement
produces even more enduring associations than continuous reinforcement
-- if you doubt this fact, just watch the "one-armed bandit"
players in any casino for a while. The intermittent reinforcement
effect is just as true for the pill that is followed by relief
every now and then, if there is no other apparent relief mechanism
available.

Superstitious conditioning. I have been discussing a
situation where there actually is a causal relationship between
the hot stove and pain and perhaps between pill and relief. However,
our nervous systems have no direct way of knowing that. That conclusion
belongs to the realm of reason, not experience. Suppose that by
happenstance, a child reaches for a new toy just as there is a
terrible clap of thunder that frightens him or her. The association
will be set up between toy and the fearful noise, and the child
may from now on avoid that toy. This is referred to as superstitious
conditioning. It is interesting to note that the term "superstitious"
is applied by the observer who knows that there really is not
a causal link. In fact, most of the time, when we are inferring
causality, we cannot really tell whether there is a causal link
or not. We take the vitamin C and feel better, or we don't catch
a cold; did one cause the other? We are likely to think so --
especially if we have other reasons—authority, testimonials,
and beliefs consistent with that interpretation. Only very careful
and time-consuming research can really tell us whether there is
any causality involved at all.

Intellectual Learning

Be that as it may, while our experiential learning is of vital
importance for survival, the major reason that we have triumphed
over other species and made them part of our food chain, rather
than the other way around, is that we possess relatively advanced
cognitive abilities. With our rich heritage of logical analysis
and our culturally-codified knowledge base, we are able, through
contemplation, to estimate the value and meaning of most things
around us. And through our highly efficacious communication abilities,
we can teach our children about "how things work," without
the need for them to go out and experience everything firsthand,
or to develop intellectual understanding from basic principles.
(Now, if we could only get them to pay attention!)

Yet, we have to learn how to learn in this way. We have to
learn logic. We have to learn how to organize our knowledge into
categories and categories into an explanatory framework. We have
to learn that surface appearances don't always relate to underlying
realities. And just as it took civilization thousands of years
to develop what we think of today as logic and scientific inquiry,
so each individual spends many years in formal education. In this
way, each of us is taught how to think in a logical manner, although,
strangely enough, not all that much of children's formal education
is devoted to developing logical abilities that will serve them
well in everyday life. There is no reason why we could not teach
children in grade 5 about the need for double-blind randomized
clinical trials, especially if we used age-appropriate, attention-grabbing
examples. They could understand, and it would be a big step towards
fostering critical thinkers, savvy consumers, and informed voters.

Human beings are constantly seeking to "understand."
We want explanations for events around us. What was that noise
in the garage? There should be no one in there—is it a raccoon,
a burglar, the wind, or am I just "hearing things"?
Why isn't my doctor curing my condition? We make causal attributions
continually—the floor is wet because the shower curtain was
not all the way into the bathtub. The tree branch was blown down
by the wind. Martha ignored me because she is envious. Harry was
nice to me because he wants to borrow some money. I got better
because I took the erythromycin. And most of us are uncomfortable
when we are unable to assign causes to events. "Harry is
floating in midair. Shucks, that is strange; but I don't have
an explanation, so I will just forget about it." Martha recovered
from terminal cancer, when the doctors said she would die—it
must have been the laetrile that saved her, or it must have been
the prayer. Most of us, in our personal lives, have a hard time
accepting ambiguity, accepting that sometimes we just don't know.

Conflicts between the Experiential and the Intellectual

As determined as we may be to base our decisions on fact, not
faith; intellect, not emotion; reason, not rhetoric; we can do
so only up to a point. Like it or not, our lives are to a considerable
degree governed by primitive associations hardened into our nervous
systems by experience.

There will be times where we "know" one thing intellectually,
but "feel" strongly something else. You may "know"
that the garter snake in the cage cannot really hurt you, but
you cannot push yourself to touch it. You may "know"
that flying through turbulence is not dangerous and no different
than being on a motor boat on some choppy water, but nonetheless,
you may feel irrational, even incapacitating, fear.

What do we do when faced with the choice between going with
logic or emotion, reason or intuition? As much as we may be dedicated
to reason, emotion has a very forceful way of making us an offer
that is hard to refuse. As the public speaker seized by stage
fright knows all too well, we cannot by virtue of rationality
or willpower simply turn off those powerful feelings—and they
are often impossible to ignore. Sometimes, the easiest way to
reduce the conflict is to bring the intellect into line with the
emotions, because most often we cannot do the opposite [8]. "Yes,
airplanes are dangerous—my fear is justified." And if
evidence-based medicine can't cure you, and alternative medicine
says it can, which do you believe? Many people experience a decrease
in anxiety if they accept the alternative healer's claims, and
that anxiety relief may thwart whatever challenges are mounted
by data and intellect.

Beliefs

Our beliefs are, in essence, our expectations about the world
around us. I believe the road continues on the other side of the
hill. I believe that submitting to surgery will take away the
pain in my belly, even it the pain initially increases. I believe
that oil of tangerine will cure my headaches. But where do our
beliefs originate?

From direct experience: I had a bad headache, took oil of
tangerine and it went away.

From watching others: Mum always took oil of tangerine whenever
she had a headache.

From logical, analytical thought—evaluating research on
oil of tangerine.

From authority, being taught directly by parents, teachers,
media: "Now children, don't forget to take your oil of tangerine."

Authority is, of course, a primary source of belief. We spend
many years in school, being pushed to master sets of facts provided
by authority, most of which we have very limited means to challenge.
Similarly, the media bombard us with assertions that many are
inclined to accept because, "They couldn't say that on TV
if it weren't true, could they?" And our most unshakeable
beliefs are often those for which we have no direct experiential
support, but have come down to us from one authority or another,
and are shared by people around us. For example, we learn that
the earth is not flat—despite whatever our direct experience
of it might suggest, and even though it is the rare person indeed
who has ever actually tried to conduct research into the claim.
Most would not even know where to begin. But we do not hear many
people expressing doubt on the matter. We all accepted what was,
initially at least, handed down by authority. And if someone in
authority, even if that authority is self-proclaimed, tells me
to reduce the amount of fat in my diet in order to preserve my
health, or tells me to take St. John's Wort if I am depressed,
why shouldn't I believe?

Our beliefs become integrated into a fabric that makes them
difficult to change, even if information that contradicts them
comes along [9]. If I come to believe that chiropractic is effective
therapy, then even if research studies find no benefit, "it
must work—it helped my back, my uncle swears by it, health
insurance covers it, a regulatory body supervises it. One study
isn't going to convince me that all those people are wrong."
This is as true for our personal beliefs about aspirin or penicillin
as it is for chiropractic or Echinacea.

Of course, the social support resulting from a sharing of belief
is important. If you have never heard of oil of tangerine until
I mention it, you may hesitate to take it, but if you have read
testimonials about its virtues; if you have other acquaintances
who use it, it is more likely that you will try it, and you will
want it to work. You may reason, "What's the harm—if it
doesn't work, at least it can't hurt me"—or so many people
are predisposed to believe about alternative therapies.

Of course, we do learn to be skeptical, too. We soon learn
that not all sources of information are equally reliable, and
as we become better educated by life, we come to accept information
from some sources almost without question, while routinely discrediting
information from other sources. But how do we choose our sources,
our authorities? I allow certain people wearing white coats to
inject substances into my veins, almost at their whim, or to put
their fingers in orifices that they were not designed to enter,
without being told anything other than the potion or the prodding
will have a therapeutic or diagnostic benefit. Yet, certain other
people in white coats who may want to give my neck a good twist
or insert tiny needles into my skin with the promise of bringing
benefit I do not allow near me. Why not? We all have learned to
choose our authorities.

Illness and Healing

Now let's turn to a series of questions about illness and healing:

How Do We Know We Are Ill?

Language is a wonderful tool for disseminating knowledge about
most things in our world. However, since we have no method of
determining whether or not a child is in pain, or whether or not
a child is frightened or worried, except by judging his or her
behavior, how do we know what a child is feeling? Of course, we
do not, not before the child can talk. We may measure the child's
temperature and decide that there is fever, but is the inference
that the child feels in pain or sickly necessarily correct? We
don't know.

We teach young children about their emotional states, about
pain, about sickness, by our judgments of what they must be feeling
or should be feeling. We teach them the language of pain and illness:
"I feel like I am going to die" or, "It's nothing,
just a flesh wound." We teach children to relax or to worry,
based on our reactions to our definition of what is going on inside
them. We teach children—and this is in part culturally based
of course, a sick role—how they are to react—to be passive,
dependent, let the parent or doctor take care of them [10]. And
since, even as we grow up, the innards of our bodies remain to
a very large extent unknown to us, we teach children to rely for
the most part on other people—on authorities—to tell them
what is wrong and to fix the problem. We learn that when we are
sick, our job as patient is to follow orders and the doctor's
job is to make us better.

But I come back to the question of how we know we are sick.
Generally, it is simply because we don't feel well, or we are
vomiting, or we are always tired, or we experience pain, dizziness,
or difficulty moving. None of these necessarily means that we
are have a disease, but we are likely to view them as problems
that need treatment. Indeed, some people grow up learning to interpret
many aspects of emotional distress as having a physical rather
than an emotional basis [11]. And so we go to the physician or
homeopath or chiropractor.

How Do We Choose a Therapist or Therapy?

The choice of therapy brings us back to the subject of authority
again. For most people, credentials are very important. But what
are credentials? A Doctor of Medicine has credentials. A Doctor
of Chiropractic has credentials, as does a Doctor of Naturopathy
or a Doctor of Traditional Chinese Medicine. How is the public
to choose among them? A Doctor is a Doctor is a Doctor to most
people. When pharmacies promote herbal remedies alongside pharmaceuticals,
when the nursing profession does not speak out against laying
on of hands ("therapeutic touch"), and supposedly responsible
media programs tout the benefits of unproven therapies, how is
the public to choose among the various credentialed authorities?
Not even looking for a basis in science is enough: Just as during
wartime, when each nation proclaims that "God is on our side,"
so too do most promoters of therapy—whether conventional or
alternative—claim science as their ally. Homeopathy, we are
told, has passed scientific muster. Chiropractic is described
as an art and a science and a philosophy. Say, which is that "scientific"
medicine again?

Moreover, we happen to live in an age where there is, in many
quarters, a growing distrust of established authorities. Today's
distrust of authority is based in part on a devolution of social
power that brings more and more decision making to the level of
the individual, leaving less and less control in the hands of
politicians, priests, physicians, and professors. On the whole,
this is probably a positive development. However, when people
are encouraged to make choices about health care, but are missing
the tools they need to weigh one therapy against another, they
are not necessarily better off, and may sometimes be much worse
off, than when designated authorities made such decisions for
them.

What if the Therapist Says There Is Nothing Wrong?

What if the family physician informs you that the vomiting
is due to stress and you should change careers, or tells you that
your pain is just something that you will have to live with? Doctors
are supposed to make us well. There is nothing in television advertising
that says "Live with your headaches" or "There
is not a pill for everything." If the doctor isn't making
us well, then maybe we need another doctor. And if that doctor
fails, then maybe we need another kind of therapy—at least
one where they promise relief.

How Do We Know That a Therapy Works?

When we are given therapy for our problem, how do we know it
works? I come back to where I started out, with the antibiotic.
It works—we surmise—if we feel better. It works if our sore
throat goes away or our backache improves or our warts disappear.

There are many reasons why we might feel improvement, however,
even if the therapy has absolutely no effect. We may feel better
after the treatment, even if it really had no effect, because:

We were on our way to recovery anyway, or our symptoms fluctuate
and we interpreted a temporary improvement as being due to the
treatment.

We never really had the disease—the symptoms were psychosomatic;.

We believed that the therapy would work, and therefore relaxed
and slept better and ate better and helped our bodies along in
that way. Perhaps the therapy motivated other things that were
helpful—e.g., given a natural medicine and told to avoid alcohol,
we moderated our drinking; given a spinal manipulation, we came
away feeling that the therapist really cares about us; given
a herb, we mobilized the joint more, despite some initial pain.

We want to believe that we are getting better, and so we
reinterpret the symptoms and minimize their severity.

These and other factors [12], can lead us to perceive improvement
in our symptoms as being caused by the treatment, thereby validating
both therapy and therapist, and setting into play a new round
of testimonials.

Incidentally, if "feeling better" is one criterion
for judging a therapy as effective, what happens if we did not
feel bad in the first place? Consider this: Research indicates
that at least one-third of all patients do not comply with the
medical regime suggested by their physicians [13]. Noncompliance
is a particular problem when patients do not know they have a
problem until they undergo a routine checkup. For example, even
though hypertension can lead to stoke, heart failure, renal failure,
and blindness, between 75 and 90 percent of patients diagnosed
with this disorder fail to take their medication regularly or
follow other recommendations[14]. Why such noncompliance? In part,
it may be because the symptoms of hypertension are not usually
obvious to the patient, who may wish to minimize the perceived
threat by persuading him- or herself that there really is not
a problem. This is a kind of "alternative nonmedicine"
-- if you feel all right, don't take anything!

However, there is more to it than that. The research literature
shows that patients comply more when they regard their physician
as caring, friendly, and interested in them[15]. Patients are
also more likely to comply when physicians make definite follow-up
appointments in order to monitor progress [16]. This again points
to an advantage that some alternative therapists have over conventional
physicians—increased specialization and technology and the
economics of managed, third-party-payer health care tends to produce
a rationing of the leisurely "bedside manner" that many
patients crave almost as much as effective therapy itself. Alternative
healers can cater to this need for reassurance, existential support,
and sympathetic human interaction by being more friendly, chatty,
taking more time, and scheduling a series of "maintenance"
or "wellness" appointments. This in itself is not necessarily
a bad thing, unless the alternative healer offers something dangerous,
extracts unconscionable sums of money, or diverts the patient
from proven therapies.

Alternative Medicine vs Scientific Medicine

So, when we ask "What makes people think that alternative
remedies work?" we should first ask ourselves "What
makes people think that conventional medicine works?" The
answer to the two questions is pretty much the same. We think
they work largely "because" we feel better after taking
them, or authorities tell us that we are better. Post hoc ergo
propter hoc, after the fact, therefore because of the fact. (Note
that I am discussing the reasons for belief in a therapy, and
not the efficacy of the therapy, per se). Proponents of alternative
therapies are largely winning the public relations war with their
hopeful, uplifting messages, whereas proponents of scientific
biomedicine have so often assumed that the superiority of their
product was self-evident (while underestimating the strength of
the "antidoctor backlash" in society).

Alternative remedies have appeal to the extent that conventional
remedies fail to provide relief. Indeed, the areas where alternative
therapies seem to have most appeal is in the very areas where
conventional therapies are not able to satisfy the expectations
of the consumer, e.g., chronic headaches and backaches, low energy,
nausea, arthritis, gastrointestinal complaints, allergies, things
which are often caused by or exacerbated by stress or emotional
disorders. The alternative therapist, through validating the client's
complaints (and often his or her unconventional worldview), providing
hope for overcoming the complaints, and giving much personal attention
and support, can indirectly serve some of the emotional needs
that often underlie many complaints that physicians dismiss. They
also offer hope for conditions that physicians cannot cure.

Remember Chuanbeiye, the snake bile preparation I mentioned
at the beginning? On the back of the box is written the following:

This is an efficacious drug for sputum crudum, cough, asthma
caused by cold, bronchitis and bronchitis chronic, etc. Because
it is very sweet and convenient for taking therefore it is very
welcomed by diseases at home and abroad. The effective rate that
treats these diseases is 96.8% and the apparent effective rate
is more than 76.8%.

That seems to suggest that some people get better but don't
realize it! Whatever the author really meant to say, as patients
with a disease, we have to leave it to medical scientists to establish
the real effective rate. All our experience tells us about is
the apparent effective rate, how often we seem to improve when
we take the medicine, whether it actually helps or not. For the
reasons I have discussed in this paper, it should not be surprising
that alternative medicine is capable of producing "apparent
effective rates" that are even higher in some circumstances
than those produced by evidence-based medicine. Ultimately, therein
lies their appeal.